Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Vinnie Jones’ hard and fast Hands-only CPR

For a view on what to do for cardiac arrest from across the pond (closed captioning is available at YouTube for those who are accustomed to American accents), there is this nice short video from the British Heart Foundation with Vinnie Jones.

One criticism is that the compressions demonstrated are on an actor, so there is not the ability to demonstrate proper depth of compressions. Especially on the actor portraying the dead guy. He looks bigger than average, so a depth of 3 inches might be more appropriate.

What about breathing?

The 2010 guidelines eliminate ventilations.

Due to a misunderstanding of the scientific method, EMS is still supposed to provide these unproven ventilations.

How will any patient recover without breathing?

The explanation is that metabolism slows down during cardiac arrest, so the oxygen that is already in the body is adequate for the needs of the body. The oxygen that is passively exchanged due to chest compressions keeps the level of oxygen from dropping quickly.

If we were to provide any ventilations, we should probably only use tiny volumes and not bag the patient any faster than 10 times a minute – even after an endotracheal tube is in place.

One huge problem with ventilations is that they increase intrathoracic pressure and keep the blood from getting where we want it.

If the blood does not circulate, then it doesn’t really matter how much oxygen is in the blood, does it?

Ventilations can prevent circulation. PPV (Positive Pressure Ventilation) can be as bad as interruptions in chest compressions. If we have to interrupt chest compressions, just to provide ventilations, we are not doing our patients any favors.

What does it say in the AHA (American Heart Association) CPR guidelines?

How can bystander CPR be effective without rescue breathing? Initially during SCA (sudden Cardiac Arrest) with VF (Ventricular Fibrillation), rescue breaths are not as important as chest compressions because the oxygen level in the blood remains adequate for the first several minutes after cardiac arrest. In addition, many cardiac arrest victims exhibit gasping or agonal gasps, and gas exchange allows for some oxygenation and carbon dioxide (CO2) elimination.110,111,119 If the airway is open, passive chest recoil during the relaxation phase of chest compressions can also provide some air exchange.19,110,111,119–122 [1]

So why didn’t the AHA make Hands-Only CPR the treatment used by all people – yet?

Clinical question.
In adult and pediatric patients with cardiac arrest (out-of-hospital and in-hospital) and receiving chest compression only CPR (P), does the addition of any passive ventilation technique (eg positioning the body, opening the airway, passive oxygen administration) (I) as opposed to no addition (C), improve outcome (O) (eg. ROSC [Return Of Spontaneous Circulation], survival)?
[2]

The problem is that the question is backwards. In evidence-based medicine, the way to state a hypothesis is to ask – Does the addition of the intervention improve outcomes?

Compared to what?

Compared to doing nothing or compared to an inert facsimile of the intervention (placebo).

To turn the question around is to give an unfair advantage to treatments that do not work. This is what the alternative medicine quacks would love, but it is completely dishonest.

If a treatment is not better than doing nothing, then we should do nothing. The treatment is not going to make anything better.

If a treatment is not better than doing nothing, but there are side effects, then we should prohibit the treatment. The treatment will sometimes make things worse, but it cannot be expected to make things better.

Does the addition of ventilations to chest compressions improve survival?

I do not see any evidence that there is any added benefit from adding ventilations.

they permitted paramedics to choose, in a nonrandomized way, whether the patient would receive some interposed ventilations versus passive insufflation of oxygen during the continuous chest compressions. These studies by Kellum do not identify the compliance with providing these additional interventions, but these interventions are associated with almost no complications. [2]

almost no complications.

almost?

Is that like almost avoiding a crash?

Is that like almost winning the lottery?

Is that like almost passing a test?

Is that like almost having a safe flight?

Is that like almost resuscitating patients?

As I stated above – If a treatment is not better than doing nothing, but there are side effects (complications), then we should prohibit the treatment. The treatment will sometimes make things worse, but it cannot be expected to make things better.

For example –

Ventilations can cause gastric inflation

Ventilations can cause . . . regurgitation and aspiration[3]


Image credit.

A carved pumpkin is not going to get any deader by vomiting in its airway.

A cardiac arrest patient who is lying on his back is not going to get any better by vomiting in his airway.

Everything gets worse.

Ventilation increases intrathoracic pressure

Ventilations decreases venous return to the heart

Ventilation diminishes cardiac output[3]
 

If the blood does not circulate, then it doesn’t really matter how much oxygen is in the blood, does it?
 

The logical conclusion is that ventilation interferes with everything good about CPR.

Ventilation diminishes . . . survival

Footnotes:

[1] Hands-Only CPR
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 5: Adult Basic Life Support
Adult BLS Skills
Free Full Text from Circulation with link to PDF Download

[2] Passive ventilation techniques
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 5: Adult Basic Life Support
Appendix: Evidence-Based Worksheets
PDF download of worksheet pages

[3] Pit Crew CPR is Just ADHD CPR
Rogue Medic
12/22/2011
Article

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Comments

  1. How excellent is that!

    I’d been given the rhythm of “Stayin’ Alive” as a good one for chest compressions some years ago when giving First Aid training.

    Unfortunately I don’t think I made the same impact as Vinnie Jones will!

  2. I agree with what you have said here, and it especially holds true in the case of a witnessed sudden cardiac arrest.

    My question is, are the results any different when the initial arrest is primary due to a respiratory cause? For example, what about a patient who has overdosed on narcotics and is now in cardiac arrest secondary to respiratory arrest?

    • Prehospital RN,

      I agree with what you have said here, and it especially holds true in the case of a witnessed sudden cardiac arrest.

      Thank you.

      My question is, are the results any different when the initial arrest is primary due to a respiratory cause? For example, what about a patient who has overdosed on narcotics and is now in cardiac arrest secondary to respiratory arrest?

      Unfortunately, the AHA also focuses on that small fraction of patients and assumes that EMS and emergency nurses and emergency physicians are too stupid to recognize signs of a primary respiratory arrest or be able to identify a patient as pediatric.

      Even though the increased survival from cardiac arrest of cardiac origin is likely to be much larger, than any possible decrease due to primary respiratory arrest being inappropriately treated with just compressions, the decision was made to adopt the method likely to produce fewer resuscitations. This is not really a surprise, when you look at the other treatments that AHA recommends without evidence – epinephrine, amiodarone, lidocaine, vasopressin, et cetera in cardiac arrest. A rule limiting NTG (NiTroGlycerin) to 3 tabs/sprays with no evidence of benefit, but plenty of evidence of harm.

      It is more about coddling the old timers on the resuscitation committees until they need resuscitation themselves. Then maybe the hokus pokus will die with them.

      .